Should a patient with atherosclerotic heart disease continue taking Plavix (clopidogrel)?

From the Guidelines

For most patients with stable atherosclerotic heart disease, long-term Plavix (clopidogrel) is not recommended as standard therapy, and aspirin 81mg daily is typically the preferred antiplatelet medication for chronic management. The decision to continue Plavix should be individualized based on specific patient factors and should not be automatic. According to the 2018 standards of medical care in diabetes 1, aspirin therapy (75–162 mg/day) is recommended as a secondary prevention strategy in those with diabetes and a history of atherosclerotic cardiovascular disease. Plavix is most beneficial when used for specific durations after events like heart attacks or stent placements (typically 1-12 months depending on stent type and bleeding risk), or in patients who cannot tolerate aspirin, as supported by the 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease 1. The rationale is that while Plavix effectively reduces platelet aggregation and prevents clot formation, it also increases bleeding risk, and this risk-benefit balance doesn't favor routine long-term use in stable disease. Key considerations include:

• The patient's individual cardiovascular risk profile
• Comorbidities
• Specific indications for Plavix, such as recent acute coronary syndrome or stent placement
• Bleeding risk, as patients with high bleeding risk may not be suitable for long-term Plavix therapy Patients currently on Plavix should consult their cardiologist before making any changes, as individual factors may warrant continued therapy in some cases.

From the FDA Drug Label

1.2 Recent MI, Recent Stroke, or Established Peripheral Arterial Disease 14.2 Recent Myocardial Infarction, Recent Stroke, or Established Peripheral Arterial Disease 14.3 No Demonstrated Benefit of Clopidogrel plus Aspirin in Patients with Multiple Risk Factors or Established Vascular Disease

The patient should not necessarily continue on Plavix (clopidogrel) simply for having atherosclerotic heart disease.

• The indications for clopidogrel include recent MI, recent stroke, or established peripheral arterial disease, but atherosclerotic heart disease alone is not explicitly listed as an indication.
• Additionally, section 14.3 states that there is no demonstrated benefit of clopidogrel plus aspirin in patients with multiple risk factors or established vascular disease, which may include atherosclerotic heart disease 2.

From the Research

Atherosclerotic Heart Disease and Plavix

• Atherosclerotic heart disease is a condition where the arteries become narrowed and hardened due to the buildup of plaque, leading to reduced blood flow to the heart 3, 4, 5, 6.
• Plavix, also known as clopidogrel, is an antiplatelet medication that helps prevent platelets from clumping together and forming blood clots, which can cause heart attacks and strokes 3, 5, 6.

Use of Plavix in Atherosclerotic Heart Disease

• Studies have shown that clopidogrel, when used alone or in combination with aspirin, can improve outcomes in patients with atherosclerotic heart disease by reducing the risk of major adverse cardiovascular events 3, 5, 6.
• The combination of aspirin and clopidogrel has been shown to have a stronger antiplatelet effect than aspirin alone, providing superior antithrombotic protection in coronary, cerebral, or peripheral arterial disease 5.
• However, the use of dual antiplatelet therapy with aspirin and clopidogrel has been associated with an increased risk of bleeding, and further studies are needed to determine the optimal duration and dosage regimen of such combination therapy to maximize its risk-benefit ratio 3, 7.

Duration of Plavix Treatment

• The optimal duration of treatment with dual antiplatelet therapy after stenting, especially with newer drug-eluting stents, is still being studied, and rapidly accumulating evidence is helping to guide treatment decisions 4, 7.
• A systematic review and network meta-analysis found that aspirin and ticagrelor for 3 months, followed by aspirin and clopidogrel for the remaining duration, can be considered the optimal strategy for treating post-percutaneous coronary intervention patients with acute coronary syndrome 7.

Considerations for Continuing Plavix

• Patients with atherosclerotic heart disease should discuss the benefits and risks of continuing Plavix treatment with their healthcare provider, taking into account their individual risk factors and medical history 3, 5, 6.
• The decision to continue Plavix treatment should be based on the available evidence and current treatment guidelines, and patients should be closely monitored for any adverse effects or interactions with other medications 3, 4, 5, 7, 6.